Complex combined cortical and internal watershed infarction: clinical case presentation and pathogenesis review

Abstract

Abstract Objective and Background: The watershed (WS) infarcts development mechanism still remains very controversial, although mainly a hemodynamic cause is usually presumed. Herein we report a very rare case of complex combined and concomitant cortical and internal watershed infarctions and discuss its patomechanism and clinic-radiological correlation. Clinical case presentation: A 45-year-old female subject was sent from an urgency ambulance to Urgent Medicine, Neuroradiology Department suspected with clinical signs of left-sided weakness, both left-sided hand and leg weakness, with difficult walking and communication, that occurred approximately few days before hospital administration. Neurological findings: conscious, communicative, left central facialis, deviation of the head to the right, partial deviation of the bulbus to the right, left hemiparesis of a severe degree on the left, hemineglect on the left; blood pressure 157/85 mmHg; glucose 28 mmol/l; treated for type 2 diabetes mellitus (insulin dependent) and Haschimoto thyreoiditis for several years. His endocranial magnetic resonance imaging (MRI) including diffusion weighted MRI imaging showed multi-infarct changes in the right parieto-occipital, right frontal and parietal, right capsulothalamic and in the corpus callosum (splenium and genu) as part of the so-called watershed cerebral infarcts (borderzone infarcts) with development of cortical (external) and deep (internal) border zone infarctions. Results and Conclusions: Hemodynamic instability due to chronic arterial hypertension and concomitant uncontrolled type 2 diabetes mellitus could lead to WS infarctions. The WS infarcts development mechanism is multifactorial (very often synergistic), and distinguishing WS infarcts (cortical and internal types) from other stroke types is extremely important, because different pathogenic mechanisms require different therapeutic options and treatment strategies and MRI plays a pivotal role therein.